Brief Report: Competency-Based Supervision in Motivational Interviewing for Advanced Psychology Trainees: Targeting an A Priori Benchmark.

Motivational interviewing (MI) is an evidence based intervention with considerable support for promoting behavior change across a broad range of health and mental health issues. Despite its effectiveness, challenges associated with learning the approach may limit its full implementation in many clinical settings. The aim of the present study was to evaluate a supervised MI training practicum implemented within a doctoral internship/postdoctoral fellowship training Program. The goal of the practicum was to enable each trainee to achieve expert competence in MI. Participants were 29 psychology doctoral interns and 1 postdoctoral fellow who participated in the training as part of their internship or fellowship program. Training included an initial workshop followed by a supervised practicum during which progress towards an a priori established expert competence benchmark was tracked through the use of an established coding system. Results indicated that trainees were satisfied with the supervision received. Three trainees did not achieve the a priori benchmark due to schedule conflicts. The 27 trainees who achieved the benchmark required between 4 and 20 supervision sessions to do so (mean = 9.22, SD = 3.77). With the exception of reflective listening skill, prior training, baseline skill, and self-reported motivation were not associated with number of supervision sessions required to achieve the benchmark. Implications for training and dissemination of MI in clinical settings are discussed.

The efficacy of Focused Acceptance and Commitment Therapy in VA primary care.

Focused Acceptance & Commitment Therapy (FACT) is a brief intervention based on traditional Acceptance and Commitment Therapy (ACT). Although there is a growing body of research on the efficacy of ACT for a variety of populations and disorders, there is little research to date on the use of FACT in group settings. This project is 1 of the first of its kind, as it examines data on psychological flexibility, health and mental health status, and symptom reduction from a 4-week FACT group. Participants in this study were 51 patients who attended this group as part of routine clinical care in a VA integrated primary care and mental health setting. They completed pre- and posttreatment measures of well-being, depression, anxiety, stress, psychological flexibility, and perceptions of physical and mental health functioning. Pre- to posttreatment analyses of variance demonstrated large effects for quality of life, F(1, 51) = 21.29, p < .001, η2 = 0.30, moderate effects for depressive symptoms, F(1, 51) = 11.47, p < .001, η2 = 0.08, and perceptions of mental health functioning (MCS scale), F(1, 51) = 9.67, p = .003, η2 = 0.11, and small effects for perceptions of perceived stress, F(1, 51) = 4.08, p = .04, η2 = 0.03, and physical health functioning (PCS scale), F(1, 51) = 6.60, p = .01, η2 = 0.08. There was a statistical trend for reductions in anxiety, F(1, 51) = 3.29, p = .07, η2 = 0.01, and a nonsignificant effect for psychological flexibility, F(1, 51) = 2.05, p = .16, η2 = 0.04. These data provide initial support for the implementation of a group-based FACT protocol within a VA primary care setting and help to lay a foundation for further, more controlled studies on Group FACT in future research. (PsycINFO Database Record

Does hangover influence the time to next drink? An investigation using ecological momentary assessment.

BACKGROUND: Measures of hangover are associated with current and future problematic alcohol use. At present, it is not known whether these associations reflect any direct influence of hangover events on near-term drinking behaviors. The current study aimed to determine whether hangover following a drinking episode influences time to next drink (TTND) and, if so, to determine the direction of this effect and identify any moderating personal or contextual factors. METHODS: Community-recruited, frequent drinkers oversampled for current smoking (N = 386) carried electronic diaries for 21 days, reporting on drinking behaviors and other experiences. Survival analysis was used to model data from 2,276 drinking episodes, including 463 episodes that were followed by self-reported hangover in morning diary entries. RESULTS: When tested as the sole predictor in a survival model, hangover was associated with increased TTND. The median survival time was approximately 6 hours longer after episodes with hangovers compared to those without. In a multivariate model, hangover was only significant in the presence of interaction effects involving craving at the end of the index drinking episode and the occurrence of financial stressors. Additional predictors of TTND in the final multivariate model included age, lifetime alcohol use disorder diagnosis, typical drinking frequency, day of the week, and morning reports of craving, negative affect, and stressors after the index episode. There was no association between morning reports of hangover and contemporaneous diary ratings of likelihood of drinking later the same day. CONCLUSIONS: The findings suggest that hangover has, at best, a modest or inconsistent influence on the timing of subsequent alcohol use among frequent drinkers.

Concerns related to eating, weight, and shape: typologies and transitions in men during the college years.

OBJECTIVE: How to best classify concerns related to eating, weight, and shape (CREWS) in men remains an open question. Research on men considering CREWS during different developmental periods could be particularly informative. METHOD: Focusing on one potentially dynamic developmental period, this study charts the course of CREWS in men over the college years. Latent class/latent transition analysis identified typologies of weight- and shape-influenced self judgment, limiting attempts, fasting, overeating, binge eating, self-induced vomiting, and laxative or diuretic abuse for 1,025 men over the four traditional college years. RESULTS: Three classes emerged: (1) no obvious pathological eating-related concerns (61-65%); (2) a high likelihood of limiting attempts and a moderately high likelihood of overeating (31-34%); (3) pervasive bulimic-like concerns (4-6%). Class membership was highly stable across assessment occasions. DISCUSSION: The results contribute to the growing literature on empirically derived classifications of CREWS and indicate that for many men CREWS are a chronic presence during the college years.

The subjective effects of alcohol-tobacco co-use: an ecological momentary assessment investigation.

Alcohol and tobacco use covary at multiple levels of analysis, and co-use of the 2 substances may have profound health consequences. To characterize the motivationally relevant processes contributing to co-use, the current study used ecological momentary assessment (EMA) to examine the subjective consequences of naturally occurring simultaneous use of alcohol and tobacco. Current smokers who reported frequently drinking alcohol (N=259) used electronic diaries to monitor their daily experiences for 21 days. Participants responded to prompted assessments and also initiated recordings when they smoked a cigarette or completed the first drink in a drinking episode. Momentary reports of smoking and alcohol consumption were associated with one another, and these effects remained after adjustment for occasion- and person-level covariates. When participants consumed alcohol, they reported increased pleasure and decreased punishment from the last cigarette. Smoking was associated with small increases in pleasure from the last drink. Ratings of buzzed and dizzy were synergistically affected by co-use of alcohol and tobacco. Co-use was also followed by higher levels of craving for both alcohol and tobacco. Results point to the importance of reward and incentive processes in ongoing drug use and suggest that alcohol intensifies real-time reports of the motivational consequences of smoking more strongly than smoking affects corresponding appraisals of alcohol effects.

Hangover and risk for alcohol use disorders: existing evidence and potential mechanisms.

Hangover may be related to propensity to develop alcohol use disorders (AUDs). However, the etiological role, if any, played by hangover in AUD is unclear. From a motivational perspective, hangover can be construed as either a deterrent to future alcohol consumption or a setting event for negative reinforcement that could promote deviant drinking practices (e.g., "hair-of-the-dog" drinking). Hangover could be related to AUD risk even if it does not play a direct role in promoting or inhibiting near-term drinking. For example, measures of hangover might serve as symptoms of AUD or as markers of individual differences that more directly account for AUD risk. Empirical evidence (though usually indirect) exists to support contentions that hangover is related to both risk for and protection from AUD. In this article, we briefly address variation in assessment strategies in existing hangover research because measures of hangover frequency and hangover susceptibility may prove to have different correlates. Next, we review the existing, limited evidence on relations between hangover and AUD risk. Finally, we sketch a variety of theoretically-informed hypotheses that might help delineate productive lines of inquiry for this emerging field.

Stability and change in patterns of concerns related to eating, weight, and shape in young adult women: a latent transition analysis.

Although college women are known to be at high risk for eating-related problems, relatively little is known about how various aspects of concerns related to eating, weight, and shape are patterned syndromally in this population. Moreover, the extent to which various patterns represent stable conditions or transitory states during this dynamic period of development is unclear. The present study used latent class and latent transition analysis (LCA/LTA) to derive syndromes of concerns related to eating, weight, and shape and movement across these syndromes in a sample of 1,498 women ascertained as first-time freshmen and studied over 4 years. LCA identified 5 classes characterized by (a) no obvious pathological eating-related concerns (prevalence: 28%-34%); (b) a high likelihood of limiting attempts (prevalence: 29%-34%); (c) a high likelihood of overeating and binge eating (prevalence: 14%-18%); (d) a high likelihood of limiting attempts and overeating or binge eating (prevalence: 14%-17%); and (e) pervasive bulimic like concerns (prevalence: 6%-7%). Membership in each latent class tended to be stable over time. When movement occurred, it tended to be to a less severe class. These findings indicate that there are distinct, prevalent, and relatively stable forms of eating-related concerns in college women.

Reasons for abstaining or limiting drinking: a developmental perspective.

The cross-sectional and longitudinal relations between reasons for abstaining or limiting drinking (RALD) and abstention were examined in a 16-year longitudinal study (N = 489) of college students with and without a family history of alcohol problems. Results indicated that RALD based upon upbringing or religiosity were associated with increased rates of abstention, whereas RALD based upon perceived or experienced negative consequences of drinking were associated with lower rates of abstention and increased alcohol consumption among drinkers. In addition, changes in RALD over time coincided with alcohol consumption transitions. Abstainers who began drinking after turning 21 reported a decrease in the importance of RALD associated with loss of control and upbringing or religiosity compared to abstainers who continued to abstain after turning 21. Conversely, drinkers who began abstaining after leaving college reported an increase in the importance of RALD associated with loss of control and upbringing or religiosity compared to drinkers who continued to drink after leaving college. Examining the reciprocal influences of RALD on drinking outcomes extends previous research and may inform prevention and intervention programs among college drinkers.

Are there developmentally limited forms of bipolar disorder?

Bipolar spectrum disorders have traditionally been thought to be chronic in course. However, recent epidemiologic research suggests that there may be developmentally limited forms of bipolar disorder. Two large, nationally representative studies reveal a strikingly high prevalence of bipolar disorders in emerging adulthood (5.5%-6.2% among 18-24-year-olds) that appear to resolve substantially during the latter half of the 3rd decade of life (3.1%-3.4% among 25-29-year-olds). Although ascertainment bias due to early mortality, institutionalization, incarceration, and homelessness may account for some of this reduction, the prevalence distribution suggests a high incidence in late adolescence and emerging adulthood that appears to resolve spontaneously in most cases. There were very few differences across age groups in symptom endorsement and comorbid diagnoses, suggesting that 18-24-year-olds that meet criteria for bipolar diagnoses experience clinically significant impairment and associated consequences of the disorder. More fine-grained longitudinal research is needed to determine whether developmentally limited forms of bipolar disorder exist and, if so, what markers might distinguish these forms of the disorder from more chronic courses.

College student receptiveness to various alcohol treatment options.

OBJECTIVE: Heavy episodic drinking remains a significant problem on college campuses. Although most interventions for college students are behavioral, pharmacological treatments, such as naltrexone, could provide additional options. PARTICIPANTS: The authors evaluated receptivity to various alcohol treatment options in a general population of college student drinkers (N = 2,084), assessed in 2005. METHODS: The authors asked participants to indicate which of 8 treatment options (ie, self-help book, self-help computer program, self-help group, group therapy, individual therapy, monthly injection, targeted oral medication, or daily oral medication) they would be willing to consider if they were going to cut down on or stop drinking. RESULTS: Over 50% of drinkers expressed receptiveness to self-help options or psychotherapy options, and over 25% of drinkers expressed receptiveness to medication options. CONCLUSIONS: Increasing treatment options for students interested in reducing or stopping drinking by offering pharmacological interventions such as naltrexone could provide an important unmet need among college students.

The effect of dialectical behavior therapy skills use on borderline personality disorder features.

We assessed the effect of DBT skills utilization on features of borderline personality disorder as measured by the Personality Assessment Inventory-Borderline Features Scale (PAI-BOR). Participants were outpatients (N = 27) enrolled in a dialectical behavior therapy (DBT) program in a university-affiliated community mental health clinic. Diary cards were collected each week to track self-reported skills use. At the beginning of each new skills training module, patients completed another PAI-BOR. Univariate and multilevel analyses indicated significant improvement on the total PAI-BOR score and on several PAI-BOR subscale scores. Results also revealed that overall DBT skills use increased significantly over time, as did individual skills related to mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Multilevel modeling results indicated that overall skills use showed a significant effect on PAI-BOR total scores, Affective Instability scores, Identity Problems scores, and Negative Relationships scores, even after controlling for initial levels of distress and diary card compliance.

A brief readiness to change drinking algorithm: concurrent validity in female VA primary care patients.

Brief primary care interventions for alcohol use should be tailored to patients' readiness to change; however, validated measures of readiness to change are too lengthy to be practical in most primary care settings. We compared a readiness to change drinking algorithm (RTC Algorithm) based on three standardized questions to a validated 12-item readiness to change questionnaire (Rollnick RTCQ) in 85 hazardous drinking female Veterans Affairs (VA) patients. Results from comparisons of mean Rollnick RTCQ scale scores across RTC Algorithm categories suggest good concurrent validity. Regular assessment using the RTC Algorithm questions may help primary care providers tailor alcohol-related discussions with hazardous drinking patients.

Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients.

BACKGROUND: Primary care providers need practical methods for managing patients who screen positive for at-risk drinking. We evaluated whether scores on brief alcohol screening questionnaires and patient reports of prior alcohol treatment reflect the severity of recent problems due to drinking. METHODS: Veterans Affairs general medicine outpatients who screened positive for at-risk drinking were mailed questionnaires that included the Alcohol Use Disorders Identification Test (AUDIT) and a question about prior alcohol treatment or participation in Alcoholics Anonymous ("previously treated"). AUDIT questions 4 through 10 were used to measure past-year problems due to drinking (PYPD). Cross-sectional analyses compared the prevalence of PYPD and mean Past-Year AUDIT Symptom Scores (0-28 points) among at-risk drinkers with varying scores on the CAGE (0-4) and AUDIT-C (0-12) and varying treatment histories. RESULTS: Of 7861 male at-risk drinkers who completed questionnaires, 33.9% reported PYPD. AUDIT-C scores were more strongly associated with Past-Year AUDIT Symptom Scores than the CAGE (p < 0.0005). The prevalence of PYPD increased from 33% to 46% over the range of positive CAGE scores but from 29% to 77% over the range of positive AUDIT-C scores. Among subgroups of at-risk drinkers with the same screening scores, patients who reported prior treatment were more likely than never-treated at-risk drinkers to report PYPD and had higher mean Past-Year AUDIT Symptom Scores (p < 0.0005). We propose a simple method of risk-stratifying patients using AUDIT-C scores and alcohol treatment histories. CONCLUSIONS: AUDIT-C scores combined with one question about prior alcohol treatment can help estimate the severity of PYPD among male Veterans Affairs outpatients.

The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients.

BACKGROUND: The optimal brief questionnaire for alcohol screening among female patients has not yet been identified. This study compared the performance of the TWEAK (tolerance, worried, eye-opener, amnesia, cutdown), the Alcohol Use Disorders Identification Test (AUDIT), and the AUDIT Consumption (AUDIT-C) as self-administered screening tests for hazardous drinking and/or active alcohol abuse or dependence among female Veterans Affairs (VA) outpatients. METHODS: Women were included in the study if they received care at VA Puget Sound and completed both a self-administered survey containing the AUDIT and TWEAK screening questionnaires and subsequent in-person interviews with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Sensitivities, specificities, positive and negative likelihood ratios, and areas under Receiver Operating Characteristic curves were computed for each screening questionnaire compared with two interview-based comparison standards: (1) active DSM-IV alcohol abuse or dependence and (2) hazardous drinking and/or active DSM-IV alcohol abuse or dependence, the more appropriate target for primary care screening. RESULTS: Of 393 women who completed screening questionnaires and interviews, 39 (9.9%) met diagnostic criteria for alcohol abuse or dependence, and 89 (22.7%) met criteria for hazardous drinking or alcohol abuse or dependence. The TWEAK had relatively low sensitivities (0.62 and 0.44) but adequate specificities (0.86 and 0.89) for both interview-based comparison standards, even at its lowest cut-point (>/=1). The AUDIT and AUDIT-C were superior, with the following areas under the receiver operating characteristic curve for active alcohol abuse or dependence and hazardous drinking and/or active alcohol abuse or dependence, respectively: AUDIT, 0.90 [95% confidence interval (CI), 0.85-0.95] and 0.87 (95% CI, 0.84-0.91); AUDIT-C, 0.91 (95% CI, 0.88-0.95) and 0.91 (95% CI, 0.88-0.94); and TWEAK, 0.76 (95% CI, 0.66-0.86) and 0.67 (95% CI, 0.60-0.74). CONCLUSIONS: The TWEAK has low sensitivity as an alcohol-screening questionnaire among female VA outpatients and should be evaluated further before being used in other female primary care populations. The three-item AUDIT-C was the optimal brief alcohol-screening questionnaire in this study.

Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population.

BACKGROUND: Primary care physicians need a brief alcohol questionnaire that identifies hazardous drinking and alcohol use disorders. The Alcohol Use Disorders Identification Test (AUDIT) questions 1 through 3 (AUDIT-C), and AUDIT question 3 alone are effective alcohol-screening tests in male Veterans Affairs (VA) patients, but have not been validated in women. METHODS: Female VA patients (n = 393) completed self-administered questionnaires, including the 10-item AUDIT and a previously proposed modification to AUDIT question 3 with a sex-specific threshold for binge drinking (>/=4 drinks/occasion), and in-person interviews with the Alcohol Use Disorder and Associated Disabilities Interview Schedule. The AUDIT-C, AUDIT question 3 alone, and the 10-item AUDIT were each evaluated with and without the sex-specific binge question and compared with past-year hazardous drinking (>7 drinks/week or >/=4 drinks/occasion) and/or active Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol abuse or dependence, based on interviews. RESULTS: Eighty-nine women (22.6%) met interview criteria for past-year hazardous drinking and/or active alcohol abuse or dependence. Standard and sex-specific AUDIT-Cs were sensitive (0.81 and 0.84, respectively) and specific (0.86 and 0.85, respectively). Their areas under the receiver operating characteristic curves were equivalent (0.91, and 0.92, respectively) and slightly higher than for the standard 10-item AUDIT (0.87). A single, sex-specific question about binge drinking (modified AUDIT question 3) had a sensitivity of 0.69 and specificity of 0.94, whereas the standard AUDIT question 3 was specific (0.96) but relatively insensitive (0.45). CONCLUSIONS: The standard and sex-specific AUDIT-Cs are effective screening tests for past-year hazardous drinking and/or active alcohol abuse or dependence in female patients in a VA study.

Comparison of 3 Depression Screening Methods and Provider Referral in a Veterans Affairs Primary Care Clinic.

BACKGROUND: Concern about underdiagnosis and undertreatment of depression in primary care has led to support for routine screening. Although multiple screening instruments exist, we are not aware of studies to date that have compared different screening strategies, e.g., how the instrument is administered: by whom and in what setting. This study compared 3 separate screening strategies in terms of patient flow, coverage, patient characteristics, and other factors with the usual care system of provider referral. METHOD: We analyzed existing data from a completed randomized team trial of collaborative care depression treatment in which patients who met DSM-IV criteria for current major depressive disorder, dysthymic disorder, or both were recruited using the usual care system of provider referral (provider) and 3 separate screening strategies: (1) a 2-stage waiting room screening interview (waiting), (2) an in-clinic screen consisting of 2 self-report items embedded in a larger survey (in-clinic), and (3) a 2-stage self-report mail survey (mail). The team trial and analysis were conducted between January 1998 and July 2003. RESULTS: The usual care system of provider referral identified the most depressed patients and had relatively good coverage compared with the 3 screening strategies. Of the 3 screening strategies, the in-clinic strategy had the best coverage, while the mail strategy had the worst coverage. Provider referral patients were younger and had fewer chronic medical illnesses than did other patients. The waiting strategy identified more patients with bipolar affective disorder. CONCLUSION: While different strategies may be optimal for different resource levels and patient characteristics, this study suggests that an in-clinic self-report survey may be the best adjunct to provider referral for efficiently increasing coverage. This study also suggests that different screening strategies may capture different patient populations.

Screening for post-traumatic stress disorder in female Veteran's Affairs patients: validation of the PTSD checklist.

We evaluated the screening validity of a self-report measure for post traumatic stress disorder (PTSD), the PTSD Checklist (PCL), in female Veterans Affairs (VA) patients. All women seen for care at the VA Puget Sound Health Care system from October 1996-January 1999 (n=2,545) were invited to participate in a research interview. Participants (n=282) completed the 17-item PCL, followed by a gold standard diagnostic interview for PTSD, the Clinician Administered PTSD Scale (CAPS). Thirty-six percent of the participants (n=100) met CAPS diagnostic criteria for current PTSD. Receiver Operating Characteristic (ROC) analysis was used to evaluate the screening performance of the PCL. The area under the ROC curve was 0.86 (95% CI 0.82-0.90). A PCL score of 38 optimized the performance of the PCL as a screening test (sensitivity 0.79, specificity 0.79). The PCL performed well as a screening measure for the detection of PTSD in female VA patients.

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking.

OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared. DESIGN: Cross-sectional analyses of audiotaped appointments collected over 6 months. PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients ( N = 47) and providers ( N = 17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus. INTERVENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit. MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected "resistance" to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P =.026). CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.